Managed Long-Term Services and Supports Provider Area Service Form This form is for Anthem HealthKeepers Plus members on behalf of HealthKeepers, Inc. Provider name and doing business as per W-9: TIN: NPI: Please indicate below the type of services your agency provides. Home health Private duty nursing Personal care (skilled nursing visits) (hourly skilled nursing) Physical therapy Pediatric care Respite Speech therapy Ventilator care needs Service facilitator Occupational therapy Complex tracheostomy care Assistive technology Additional service(s): Attestation: I hereby affirm that our agency is in compliance with the provider waiver requirements as established in the Department of Medical Assistance Services provider manuals available at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal and the following regulations: 12VAC30-120-900 through 12VAC30-120-995. I also affirm that the service area information is reflective of our current service area capabilities and will need to be updated as modified by our organization s capabilities. Signature: Printed name/title: Date: Telephone: Check here if you service Virginia statewide. If so, there is no need to proceed. If you do not service Virginia statewide, review the remainder of the document and check the applicable service areas by region. Central region If you service all cities in the Central region, please check this box. Amelia (007) 23002 Amelia Lancaster (103) 22503 Lancaster Brunswick (025) 23868 Lawrenceville Lunenburg (111) 23952 Lunenburg Caroline (033) 22428 Bowling Green Mathews (115) 23109 Mathews Charles (036) Chesterfield (041) 23030 Charles Mecklenburg (117) 23917 Boydton 23832 Chesterfield Middlesex (119) 23149 Saluda https://mediproviders.anthem.com/va HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AVAPEC-1470-17 July 2017
Page 2 of 5 Colonial Heights (570) Cumberland (049) 23834 Colonial Heights 23040 Cumberland Northumberland (133) New Kent (127) 23124 New Kent 22473 Heathsville Dinwiddie (053) 23841 Dinwiddie Nottoway (135) 23955 Nottoway Emporia (595) 23847 Emporia Petersburg (730) 23803 Petersburg Essex (057) 22560 Tappahannock Powhatan (145) 23139 Powhatan Franklin (620) Fredericksburg (630) 23851 Franklin Prince Edward (147) 22401 Fredericksburg Prince George (149) Goochland (075) 23063 Goochland Richmond (760) 23901 Farmville 23875 Prince George 23220 Richmond Greensville (081) 23867 Jarrett Richmond (159) 22572 Warsaw Hanover (085) 23069 Hanover Southampton (175) 23837 Courtland Henrico (087) 23238 Henrico Spotsylvania (177) 22553 Spotsylvania Hopewell (670) 23860 Hopewell Stafford (179) 22554 Stafford King and Queen (097) 23085 King and Queen Surry (181) 23883 Surry King George (099) King William (101) 22485 King George Sussex (183) 23884 Sussex 23806 King William Westmoreland (193) 22520 Montross Tidewater region If you service all cities in the Tidewater region, please check this box. Accomack (001) 23301 Accomack Northampton (131) Chesapeake (550) 23347 Eastville 23320 Chesapeake Poquoson (650) 23662 Poquoson Gloucester (073) 23062 Gloucester Portsmouth (740) 23701 Portsmouth Hampton (650) 23630 Hampton Suffolk (800) 23432 Suffolk Isle of Wight (093) 23430 Isle of Wight Virginia Beach (810) James (095) 23185 Williamsburg Williamsburg (830) 23450 Virginia Beach 23186 Williamsburg
Page 3 of 5 Newport News (700) Norfolk (710) 23501 Norfolk 23601 Newport News York (199) 23690 Yorktown Northern/Winchester region If you service all cities in the Northern and Winchester regions, please check this box. Alexandria (510) 22301 Alexandria Loudoun (107) 20175 Leesburg Arlington (013) 22201 Arlington Manassas Clarke (043) 22611 Berryville Manassas Park 20110 Manassas 20111 Prince William Culpeper (047) 22701 Culpeper Page (139) 22835 Luray Fairfax (600) 22030 Fairfax Prince William Fairfax County (059) Falls Church (610) 22003 Annandale Rappahannock (157) 22040 Falls Church Shenandoah (171) 22025 Manassas 22747 Washington 22664 Woodstock Fauquier (061) 20186 Warrenton Warren (187) 22630 Front Royal Frederick (069) 22602 Winchester Winchester (840) 22601 Winchester Western/Charlottesville region If you service all cities in the Western and Charlottesville regions, please check this box. Albemarle (003) 22901 Charlottesville Halifax (083) 24577 Nathalie Amherst (009) 24521 Amherst Harrisonburg (660) Appomattox (011) 22801 Harrisonburg 24522 Appomattox Louisa (109) 23093 Louisa Augusta (015) 24421 Staunton Lynchburg (680) 24504 Lynchburg Buckingham (029) 23921 Buckingham Madison (113) 22727 Madison Campbell (031) 24588 Rustburg Nelson (125) 22949 Lovingston Charlotte (037) 23923 Charlotte Ct. House Charlottesville (540) Orange ( 137) 22942 Orange 22902 Charlottesville Pittsylvania (143) 24531 Chatham
Page 4 of 5 Danville (590) 24541 Danville Rockingham (165) 22802 Harrisonburg Fluvanna (065) 22963 Palmyra Staunton (790) 24402 Staunton Greene (079) 22973 Stanardsville Waynesboro (820) 22980 Waynesboro Roanoke/Alleghany region If you service all cities in the Roanoke and Alleghany regions, please check this box. Alleghany (005) 24422 Clifton Forge Lexington (678) 24450 Lexington Bath (017) 24445 Hot Springs Martinsville (690) 24112 Martinsville Bedford (019) 24523 Bedford Montgomery (121) 24068 Christiansburg Botetourt (023) 24019 Hollins Patrick (141) 24171 Stuart Buena Vista (530) 24416 Buena Vista Pulaski (155) 24301 Pulaski Covington (580) 24426 Covington Radford (750) 24141 Radford Craig (045) 24127 New Castle Roanoke (770) 24012 Roanoke Floyd (063) 24091 Floyd Roanoke (161) 24179 Roanoke Franklin (067) 24151 Rocky Mount Rockbridge (163) 24472 Vinton Giles (071) 24134 Pearisburg Salem (775) 24153 Salem Henry (089) 24055 Bassett Wythe (197) 24382 Wytheville Highland (091) 24465 Monterey Southwest region If you service all cities in the Southwest region, please check this box. Bland (021) 24315 Bland Norton (720) 24273 Norton Bristol (520) 24201 Bristol Russell (167) 24266 Lebanon Buchanan (027) 24614 Grundy Scott (169) 24251 Gate Carroll (035) 24343 Hillsville Smyth (173) 24354 Marion Dickenson (051) 24228 Clintwood Tazewell (185) 24630 North Tazewell Galax (640) 24333 Galax Washington (191) 24210 Abingdon Grayson (077) 24348 Independence Wise (195) 24293 Wise
Page 5 of 5 Lee (105) 24263 Jonesville